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   Table of Contents - Current issue
January-March 2020
Volume 28 | Issue 1
Page Nos. 1-82

Online since Tuesday, December 31, 2019

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Effect of fondaparinux on viability and ischemia reperfusion injury in the abdominal perforator flap p. 1
Guler Gamze Eren Ozcan, Hakan Agir, Murat Sahin Alagoz, Tugba Kum, Levent Trabzonlu
Objective: The epigastric artery perforator flap is commonly used in the breast reconstruction. Ischemia during surgery results in the necrosis of the flap. We aimed to study the effect of fondaparinux in reperfusion injury in perforator flap model and determined its effects on the flap viability. Materials and Methods: Twenty-eight female Wistar Albino rats were included in this study. Rats were separated into three groups: A control (n = 9), B ischemia (n = 9), and C ischemia + drug (n = 10). Superior epigastric artery perforator flap on the single perforator was elevated in all groups. In Group A, flap was sutured back. In Group B, ischemia was applied for 4 h to the pedicle. In Group C, fondaparinux was administered 30 min before the reperfusion of the flap. Serum malondialdehyde (MDA), myeloperoxidase (MPO) levels, and histopathological examination of the flaps were studied. Results: The mean survival areas of flaps were 92.5%, 50.1%, and 91.1% in Group A, Group B, and Group C, respectively. Statistical differences were observed between these values (P < 0.05). The means of MPO and MDA were 22.3 ng/ml and 4.5 nmol/ml; 31.1 ng/ml and 4.7 nmol/ml; 27.1 ng/ml and 4.5 nmol/ml, respectively, for Group A, Group B, and Group C, and no statistically significant difference was found between groups (P > 0.05). Histopathologically, statistically significant difference was found between Group A, Group B, and Group C in terms of the infiltration of the leukocytes with polymorph nuclei (PMNL) for 24 h (P < 0.05). In the histopathological examinations done at the 7th day, statistically significant difference was found between groups in terms of edema, necrosis, increase in connective tissue, and leukocytes with polymorph nuclei (PMNL) (P < 0.05). Conclusion: Administration of fondaparinux after ischemia increased the flap viability in the epigastric artery perforator flap model.
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Indications for transoral endoscopic-assisted methods in condylar process fractures p. 9
Osman Akdag, Mustafa Sutcu, Gokce Unal Yildiran, Ahmet Bilirer
Objective: Endoscopic-assisted mandibular subcondylar fracture repair is a different way of performing open reduction internal fixation and also includes surgical equipment and manipulations other than those used in the classical methods. The criteria for patient selection should be different from that of the classical methods. Materials and Methods: Between April 2012 and June 2017, treatment protocols which were applied to 56 patients with mandibular subcondylar fracture were evaluated retrospectively. The first step of this study was to evaluate why patients with mandibular subcondylar fractures were not operated endoscopically. In 34 patients, methods other than endoscopic methods were used. Characteristics of these patients and fractures were demonstrated. Results: Twenty-four patients were followed conservatively. Twenty-two patients were treated with transoral endoscopic method while ten patients were treated with the conventional open surgery. This open surgical treatment was reported by determined the patient records for why the endoscopic method was not preferred. The determined criteria were; condyle with excessive medial deviation, patient age, fracture type, general condition/anesthesia risk, and time of injury. Conclusion: In accordance with clinical experience, some criteria have been defined for patient selection preoperatively in mandibular subcondylar fractures. It believes that with the right patient selection, it will be possible to achieve better results and reduce complications.
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Pedicled thoracoumbilical flap coverage for wounds around elbow: A versatile option p. 14
Mohd Altaf Mir, Fahad Khurram, Dinesh Kumar
Background: To evaluate the reliability of pedicled thoracoumbilical flap for reconstruction of soft-tissue defects around the elbow. Materials and Methods: This was a prospective study undertaken between September 2017 and November 2018, in division of plastic and reconstructive surgery of our institution. Patients with soft-tissue defect of the elbow referred from the division of orthopedic surgery were included. Those with a scarring in the region of thoracoabdominal flap were excluded. A detailed history and examination were recorded. An informed consent was taken from every patient. Anteroposterior and lateral radiographs of the elbow were taken in all cases. Pedicled thoracoumbilical flaps were raised in all patients for the coverage of soft-tissue defects around elbow. Pedicle division and final inset were done after 4 weeks in all cases. All patients were followed up regularly. Results: A total of 5 patients with soft-tissue defect around the elbow were referred to our division from the division of orthopedic surgery. All patients were male with a mean age of 33 ± 6.67 years (25–40 years). The injuries were common in labor class, and the most common etiology being fall from height in three out of five cases. The right elbow was often injured (three out of five cases). In all patients, the wounds were of Gustilo Anderson grade IIIB. In one case, the implant was exposed (case 3). The mean defect size was 45.75 ± 6.29 cm2, and the mean flap size was 171.85 ± 13.12 cm2. No complications were seen in our case series. Conclusion: The pedicled thoraco-umbilical flap is technically simple and versatile option for the coverage of soft-tissue defect around elbow since it is vascularity is predictable.
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Analysis of wound complications of patients with meningomyelocele p. 19
Koray Gursoy, Galip Gencay Ustun, Burkay Akduman, Melike Oruc Ozpostaci, Yuksel Kankaya, Ugur Kocer
Aims: During the closure of meningomyelocele defects, complications such as dehiscence, flap loss, or cerebrospinal fluid (CSF) leaks may be encountered. There are multiple variables that have not been studied including defect size, surgical method for closure, or patient weight that may take a role during this process. Subjects and Methods: Records of patients operated between February 2015 and August 2018 were retrospectively reviewed. Age and weight at the time of operation, gender, location and size of the defect, method of closure, operative time, pre- and post-operative hemoglobin (Hb) levels, postoperative complications, and revision surgeries if needed were reviewed. Results: Among 28 patients included in the study, 9 (32.1%) patients had postoperative wound complications including partial flap loss, dehiscence, and CSF leaks. Pre- and post-operative Hb levels showed statistically significant difference between primary cases and revision cases (P < 0.001). Defect size, change in Hb levels, and postoperative complication rates did not differ between techniques for closure, yet operative time was significantly increased in butterfly flap group. Increasing defect size was found to be associated with longer operative time and postoperative CSF leakage (P = 0.002 and P = 0.05, respectively) but showed no significant relationship with flap necrosis, dehiscence, and intraoperative blood loss (P = 0.110, P = 0.113, and P = 0.84, respectively). Conclusions: Rotation/advancement fasciocutaneous flaps provide a durable single-stage reconstruction for meningomyelocele defects. The need for transfusion must be kept in mind during primary cases. Correct choosing and application of each method limits complications even with larger defects; however, increasing defect size leads to CSF leaks and prolonged operative time.
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Evaluation of concentric periareolar subcutaneous mastectomy outcomes in transsexual patients during 2016–2017 in Iran: A clinical study p. 25
Javad Rahmati, Omid Etemad, Nafiseh Malek Mohammadi
Background: Transsexual (TS) people are those who assigned one sex at the birth but identified their gender in what society considers the opposite direction. Studies showed that gender reassignment surgery (GRS) had greatly improved the quality of life in TS patients. Materials and Methods: We studied 20 patients who had legally the permission of being underwent the sex reassignment surgery in Imam Khomeini Hospital Complex of Tehran, Iran. For all patients, concentric periareolar subcutaneous mastectomy was performed. The patients were followed up for 1 year and the results were evaluated. Results: Our findings show an acceptable scar formation after 1 year of the sex reassignment surgery. There was only one complication which was managed conservatively. About 90% of patients were satisfied from the results of surgery, and no one was less/unsatisfied. The average score of nipple sensation was 7.9 and no changes in nipple pigmentation was observed. Conclusion: Concentric periareolar mastectomy is probably a good technique of subcutaneous mastectomy in female to male GRS in patients with small and medium size of the breast and poor skin elasticity. The result scar in this method is acceptable and gives the patients a good feeling of having male chest.
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Effect of depth of invasion on lymph node metastasis in early stage p. 29
Necip Sefa Ozden, Yasemin Aydinli, Nijat Babayev, Arda Ozdemir, Burak Kaya
Introduction: Lip cancer is the most common type of cancer in the oral cavity. It occurs in the lower lip at a rate of 90%–95%, and among lower lip tumors, squamous cell carcinoma (SCC) is the most common type. Objective: In this study, we investigated the influence of the depth of invasion on the decision for an elective lymph node dissection in cases with early-stage (T1–T2 N0 M0) SCC of the lower lip. Methods: Thirty-two patients that were surgically treated were retrospectively reviewed. Results: Three patients had metastatic lymph node, and their mean depth of invasion was 10.60 mm. Lymph node metastasis significantly increased in tumors with a depth of invasion larger than 5 mm (P = 0.033). Conclusion: The rate of cervical lymph node metastasis increases as the depth of invasion increases.
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Importance and necessity of surgical combinations in the correction of prominent ears for natural and long-lasting results p. 33
Ayhan Okumus
Introduction: Many surgical methods are defined to correct prominent ears, with the most common being external auditory canal anomaly. Trying to treat cases where different anatomic structures coexist in the anomaly increases the risk of additional surgical intervention or causes an unnatural appearance. In this study, it was demonstrated that application of varying surgical combinations depending on the anatomic components which cause prominent ears would produce natural and long-lasting results. Materials and Methods: Seventy-one patients, with antihelix tube development defect, conchal hypertrophy, or both, were operated in our clinic between 2004 and 2018 (age range: 6–43 years, 42 females and 29 males). Four different methods were employed, consisting of postauricular skin excision of 0.5–1.5 cm, posterior abrasion of the antihelix and shaping with Mustarde sutures, semilunar excision from the large and mispositioned concha and connecting the ends before securing loosely to the mastoid fascia, and securing the dermo-perichondrial flap to the mastoid fascia. Three different surgical combinations were utilized on three patient groups with antihelix formation defect, concha hypertrophy, or both. Results: Patients were followed up for 2 years on an average, 6 months at minimum. No major complications were encountered except for one patient who had an opening of the upper pole, while another had it on both sides. All patients stated their satisfaction with the result. Conclusion: The purpose of prominent ear treatment should not only be formation of the antihelix or bringing the ear closer to head.Different problems can be solved separately with combined treatment, and more natural and lasting results can be obtained.
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Reconstruction of axillary hidradenitis suppurativa defects with thoracodorsal artery perforator flaps: Our clinical experience p. 38
Hasan Murat Ergani, Atakan Bas, Burak Yasar, Ramazan Erkin Unlu
Background: Axillary hidradenitis suppurativa (HS) is a chronic, debilitating condition. Sinus tracts, abscess foci, and relapsing chronic inflammation are the hallmarks of the disease, which affects about 1% of the population. Various treatment options have been used to counter the underlying inflammation, but their efficacy profile yields an unsatisfactory result. Aims and Objectives: Subpar treatment results guided us to a different treatment approach, putting surgical modalities as the hallmark of our approach. Surgical debridement of affected tissues often results in a defect, requiring a safe,effective reconstructive method. Results: Thoracodorsal artery perforator (TDAP) flap is a versatile flap which can be applied to reconstruct thoracic and axillary defects, whereas a free fasciocutaneous flap can be used as a reliable method to cover extensive defects located elsewhere in the body. In axillary HS, TDAP flap is a reliable method for reconstruction, providing adequate soft-tissue coverage, three-dimensional regular contours, and less adverse effects in the long term compared to skin grafts. Conclusion: In our article, we shared our experience with the usage of TDAP flap. Our results indicate that TDAP should be considered as a primary option in reconstruction of axillary HS defects.
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Surgical Validation of High-Resolution Ultrasonography in Detection of Missed Tendon and Nerve Injuries after Penetrating Wounds of Hand and Wrist p. 44
Mohd Altaf Mir, Imran Ahmad, Dinesh Kumar, Nitin Goyal
Background: To surgically validate high-resolution ultrasonography (USG) in the detection of missed tendon and nerve injuries after penetrating wounds of the hand and wrist. Materials and Methods: Patients with penetrating wounds of the hand and wrist were examined to determine the location of injury, size, and depth of the wound, probable tendons or nerves involved. The selected cases underwent high-resolution ultrasound of the affected part. Injuries detected were noted. The sensitivity, specificity, positive predictive value, and negative predictive values of the high resolution of ultrasound in preoperative detection of tendon and nerve injuries were calculated against the gold standard of intraoperative confirmation. Results: Fifty patients with penetrating injuries to the hand and wrist with the mean age 28.3 ± 4.7 years were admitted. The high-resolution USG of all the 50 patients 33 (66%) were found to have isolated tendon injury and 14 cases were found to have isolated nerve injury, whereas three cases were found to have both tendon and nerve injury. The injuries were compared with injuries confirmed on intraoperative exploration. The calculated sensitivity, specificity, positive predictive value, and negative predictive value of high-resolution USG for diagnosing the tendon injuries were 97.22%, 98.42%, 97.22%, and 98.42%, respectively. The calculated sensitivity, specificity, positive predictive value, and negative predictive value of high-resolution USG for diagnosing the nerve injuries were 85%, 92.85%, 89.47%, and 89.65%, respectively. Conclusion: It is concluded that high-resolution USG is significantly cheaper and dynamic diagnostic modality which can be used to provide additional information for diagnosing tendon and nerve tears and their location and types in cases of penetrating wounds of the hand and wrist.
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Pediatric dog bite injuries of head and neck: An algorithm for the treatment of our clinic p. 51
Elif Sanli, Berkan Altay
Background: Dog bite injuries are more frequent injuries than they are supposed to be in our country. Aims and Objectives: This study presents our pediatric dog bite injuries of head and neck and a simple algorithm of the treatment. Materials and Methods: A retrospective screening was done of the cases, and data was collected. Descriptive statistical analysis was done about age, sex, type of injury, time of injury, type of dog breed, and closure options. Results: A total of ten children were enrolled to the study. The mean age was 6.4 years, and most of the cases were preschool-aged children. Scalp was the most affected region at head and neck. Pit bull was the only known dog breed. The common time of the injuries was morning. Major injuries were more than minor ones, and they were closed with graft or flaps. Conclusion: We think that dog bite injuries are an important problem in our country. Therefore, further detailed multi-centered studies should be done.
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Self-efficacy in cosmetic surgery applicants compared to nonapplicants p. 55
Ali Soroush, Bahare Andayeshgar, Maryam Janatolmakan, Alireza Khatony
Context: The decision for cosmetic surgery (CS) can be influenced by psychological issues. Self-efficacy (SE) is one of the psychological factors affecting this decision. Aims: The purpose of this study was to compare SE between the CS applicants (study group) and nonapplicants (control group). Setting and Design: In this cross-sectional study, 65 samples were recruited for each of the study and control groups. Materials and Methods: The study group was selected from among the beauty centers and the control group was selected among the ordinary people who did not intend to do CS. Convenience sampling was used to select the samples of the study and control groups. The control was matched with the study group with respect to gender, age, marital status, occupation, and education. To measure SE, Sherer et al.'s General Self-Efficacy Scale was used. Statistical Analysis Used: Data were analyzed using SPSS software using descriptive and inferential statistics (Kolmogorov–Smirnov test, Chi-square test, Mann–Whitney U-test, one-way ANOVA, and independent t-test). Results: The average SE was significantly lower in the study group than the control group (P = 0.008). In the study group, there was a significant relationship between SE and education (P = 0.03). However, there was no significant relationship between SE and other demographic variables. Conclusions: The study group had lower SE than that of the control group. It seems that low SE can affect the decision to undergo CS. To avoid unnecessary cosmetic surgeries, the SE of applicants is suggested to be investigated before surgery.
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Analysis of primary rhinoplasty in elderly patients p. 60
Aret Cerci Ozkan
Background: The upper limit of rhinoplasty age increases as the concept of old age shifts forward. Rhinoplasty operations of this era have their own characteristics. The aim of this study is to point out these characteristic features and propose solutions to the problems observed in our series. Materials and Methods: Between 2014 and 2018, 32 primary rhinoplasties were performed on patients over 55 years of age. A comprehensive preoperative evaluation was done in all cases. Wider skin undermining was a prerequisite to overcome skin redundancy. Proper elevation of the droopy nose was the primary goal. Placement of a wide and homogeneously crushed cartilage graft over the lower and upper lateral cartilages was applied in all patients for structural support in addition to standard measures. In patients with extreme droopiness, a deep temporal or rectus fascial sling was applied between the columella and the nasal dorsum to support tip elevation. Results: The follow-up period was 6 months–4 years. All of the patients were satisfied with the postoperative results except for one case having dorsal irregularities and one case with postoperative relapse of the droopiness. Revisional operations of these patients were performed with the utilization of deep temporal fascia. A pulmonary embolus was encountered in one patient in 56 years of age at the 39th-postoperative day. She was hospitalized, and an anticoagulant treatment was applied. Conclusion: The most important problem in this age group is the droopiness of the tip. The use of a wide and homogeneously crushed septal cartilage graft over both the upper and lower lateral cartilages and autologous fascial sling rising and stabilizing the tip may help to prevent its relapse.
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Changes to skin cancer staging in American Joint Committee on Cancer 8th edition p. 65
Ahmet Demir, Omer Faruk Unverdi
The American Joint Committee on Cancer (AJCC) has an irreplaceable importance with its guidelines for cancer staging. These staging procedures are carried out with retrospective and prospective analysis studies. In the light of the new data, there may be an increase or decrease in the staging of some skin cancer lesions, while some concepts are completely eliminated. In the 8th Edition of the AJCC Manual, which is published approximately 7 years after the previous edition, changes were made in line with the new data on skin cancers. The most prominent change for squamous cell carcinoma of the skin is the discrimination between “clinical (cN)” and “pathological (pN)” staging. The most prominent change for Merkel cell carcinoma is that “cN” and “pN” distinction has been introduced for both regional lymph node and distant metastasis. In terms of melanoma, it can be said that everything related to a tumor, a regional lymph node, and a distant metastasis have been changed. Given the fact that the next edition will not be released earlier than at least another 7 years, it is necessary to quickly become acquainted with this new edition for the benefit of treating and monitoring patients with skin cancer.
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Successful total scalp replantation using the retromandibular vein as a recipient vessel p. 74
Can Ilker Demir, Emrah Kagan Yasar, Kivanc Emre Davun, Aykut Gok, Nicat Rustamov, Murat Sahin Alagoz
Replantation is the first treatment in scalp amputations. Venous insufficiency is the most common cause of failure. There may be difficulties caused by venous anastomosis, especially in cases with cranial bone fractures. There is no agreement about the number of vessels that should be used for replantation. Depending on the severity of the injury, there may be concurrent injuries such as spinal fractures and other system pathologies, such as cranial bone fractures. In this article, we describe and discuss the surgical treatment of a patient with a temporal bone fracture concurrent with a total hairy skin amputation, which extended from both eyebrows anteriorly, in front of the ear laterally, to the hairline posteriorly. Single-artery and single-vein anastomoses were performed. The retromandibular vein was used as the recipient vein because an alternative appropriate vein was not available. Complete improvement was achieved in our patient, both aesthetically and functionally.
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Surgical treatment of complex metacarpophalangeal joint dislocation p. 77
Mustafa Sutcu, Gokce Yildiran, Osman Akdag
Dorsal dislocations of the metacarpophalangeal joint (MPJ) are relatively uncommon injuries. Complex dislocations of metacarpophalangeal dorsal dislocations are characterized with extended MPJ without flexion and flexed distal joints. Complex dislocation injuries usually require surgical reduction. A 25-year-old male patient was admitted with pain, swelling, and tingling following a hyperextension injury. X-rays demonstrated dorsal dislocation of the proximal phalanx of the index finger without fracture. Open surgical reduction was planned via volar approach. Treating a complex MPJ dislocation with closed reduction is rarely successful. Especially, the volar approach is useful in open dislocations, and anatomy of the volar structures can be best explored and demonstrated.
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An efficient method for image archiving: Tagging images with structered keywords p. 80
Bulent Sacak
Photographic documentation is an integral part of plastic surgery practice. While there are reports in the literature that discuss photographic documentation and archive security, it is hard to find studies on image archiving and searching. This report aims to introduce a structured tagging system that can be used with all digital archiving programs and easily adapted to the everyday routine and practices of users. The system facilitates finding the images of a patient that were photographed at different times and allows to quickly and easily view all images related to a certain anatomical region or all of those that were photographed with a certain technique.
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